Coverage Not At The Expense of Density

[Hattingen Hair]

A hair transplant cannot fully replace hair lost in a 1:1 ratio (100% restoration); a hair transplant therefore strives to achieve an illusion of thickness, placing the FU ´s (grafts) in such a way to cover a surface area that in reality used to have much more hair. This basic principle allows especially people with more aggressive hair loss patterns to be able to achieve if not total but almost total coverage with a natural looking thickness or density.

The Visual Appearance of Hair Loss:

Hair Loss becomes apparent when light penetrates the hair coverage and is reflected back off the scalp surface. Our eyes can only make sense of something if there is light, if it is pitch black; there is nothing for the eye to see. So, when there is enough density the light only reflects off the hair coverage and not the scalp, therefore blocking the appearance of light and the appearance of hair loss/thinning.

Miniaturisation

The MPB hair loss process is not a sudden occurrence, but rather a prolonged process of miniaturisation, where the hair life progressively shortens its growth phase, the hair shaft becomes thinner, does not grow as long or as fast. The loss of diameter of the hair shaft leads to a loss in the coverage potential of the hair; this in turn allows light rays to reach the skin surface. The reflection that bounces back into our eyes is more and more from the skin. We see this as thinning hair or hair loss.

The goal of a hair transplant is to redistribute a sufficient amount of healthy, permanent hair from the donor area to the area of hair loss, recipient area in order to block the reflection of light off the scalp and therefore to attain the appearance of fullness.

Simply put, to try to cast a substantial shadow on the skin in order to block the light rays.

Consider the fact that your donor density on the back of your head (occipital area) is usually around 80 FU €™s/cm ², whereas the density on the lateral sides is around 65-70 FU €™s/cm ². This difference of 10-15% less density is imperceptible to the naked eye. This is proof that sufficient coverage of the skin / blocking of light rays is achievable with less than 100% of the mathematical density.
There is therefore a difference between mathematical and aesthetic density, and this is a vital aspect that makes a hair transplant work.

Coverage but not at the expense of density

The question then is how much hair has to be redistributed in order to achieve the blocking of light and an aesthetically acceptable coverage?
This depends on the individual ´s characteristics or quality of the hair (thickness of the hair shaft, curl, colour contrast between hair and skin), but also the length of the hair shaft and the way the hair is combed /styled.

It is important to understand that the hair needs to have a certain length in order to be able to develop its coverage potential. The shorter the hair is cut then less shadowing/ coverage or fullness is achieved so for most people it is important to allow the hair to grow long enough to overlap the surrounding hair and therefore enjoy the maximum result of the transplanted hair.

Besides the above mentioned factors that are not influenced by the operating team, there are some technical tricks that we can use to maximise the coverage potential of transplanted hair. A more acute angle of the recipient incision allows the hair to lay flatter onto the skin, therefore obtaining a longer shadow. The method and technique of slit making, orientation and the use of custom blades allows for greater angulation control, recreates a naturally arranged pattern of FU €™s and ultimately lead to better coverage/ better illusion of density.

Hair characteristics, correct placement angle and orientation are commonly discussed to be important to gain the illusion of thickness and greater coverage.
We touched on this in another thread; one aspect that is rarely discussed if at all is the use of the natural curvature of the hair to gain maximum coverage from each hair, and allowing the hair to blend into the native hair more effectively, so even with a shorter cut the curvature does not contradict the surrounding hair.

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[/align][align=left]This shows the FU ´s after being removed and the natural curvature, below shows when placed in the recipient 2 FU ´s with opposing curvature placement, one up the other laying down.[/align]

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[/align][align=left] Even a straight hair has a curvature, the lay of the hair when it is held up or when in the scalp will always fall in a certain direction when it exits (usually with the curvature of the hair facing down, towards the scalp). When placing a hair in the recipient site the hair shaft of the graft requires a few mm ´s in order for the technician/placer to be able to determine the correct direction of the curvature. This is pain staking work and nothing to do with the way the recipient site (direction /angle) has been made, it is solely down to the technician checking each placement as it is made and adjusting accordingly which way the hair curvature falls. [/align][align=left]
To have enough hair length visible on the FU graft in order to correctly asses the direction of the curvature means that the hair cannot be close shaved in the donor when harvested. This proves problematic with FUE as the donor needs to be close shaved in order to precisely extract; it is easier with FUT as the donor area hair can be left longer. [/align][align=left]Placing the hair with the correct curvature to the surrounding hair has three major benefits, firstly it will blend with the surrounding hair and not give the appearance of misdirected hairs, secondly it will allow each hair to give greater coverage allowing for fewer grafts to be used over a specific area of the recipient and thirdly more fullness or density can be achieved as the hairs are laying in a uniform pattern.[/align][align=left]Hair transplants are a unique blend of strategic vision, understanding of mathematical and physical facts, technical prowess and artistic feel.
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[Bigmac]

Great post, very informative for anyone considering a Ht.

 

[sl]

Nice post and shows a great understanding with the points raised.

When I think of my own case as an example i've got 8,400 or so transplanted grafts in an area that had probably well over 20,000 native grafts before loss occured and it really is about an illusion of coverage. We hear this repeated a lot but at times it can be hard for people to actually grasp, even though they give mental assent to it.

Wearing the hair at certain lengths or "sweet spots" adds to this and some will according to hair calibre look much better as they allow the hair to grow and for others a shorter cut may be favourable also. I've literally seen patients with short hair who look thin and then with long hair who have been asked if they have a wig on as the hair looks far thicker. Same patient, no more grafts at all, just allowing the hair to give coverage, and curly hair expecially needs length to do this.

The exit angle of the graft, direction and as you say curl are important aspects. The curl is hard to predict when the hair is shaved very short for FUE for example (approx 1mm), but possibly for Strip there is more leeway in this if the doctor prefers to allow a slightly longer length and therefore make the curl more indicative at placing.

Well done on a nice post that is makes some very good points and appreciate the photos also.

 

[SADbutTRUE]

cool stuff, very educational. keep it comming

 

[Hattingen Hair]

sl wrote:

Nice post and shows a great understanding with the points raised.

Wearing the hair at certain lengths or "sweet spots" adds to this and some will according to hair calibre look much better as they allow the hair to grow and for others a shorter cut may be favourable also. I've literally seen patients with short hair who look thin and then with long hair who have been asked if they have a wig on as the hair looks far thicker. Same patient, no more grafts at all, just allowing the hair to give coverage, and curly hair expecially needs length to do this.

The exit angle of the graft, direction and as you say curl are important aspects. The curl is hard to predict when the hair is shaved very short for FUE for example (approx 1mm), but possibly for Strip there is more leeway in this if the doctor prefers to allow a slightly longer length and therefore make the curl more indicative at placing.

Well done on a nice post that is makes some very good points and appreciate the photos also.

Hi sl,

As you say hair calibre, colour etc also makes a great deal of difference, the sweet spots you mention also, ensuring the correct groups of FU ´s are used in specific areas and not just randomly spread. This with the careful placement of the hair to match the natural curvature can enhance the result not just cosmetically in terms of look but also under the right circumstances allow for fewer grafts to be used to cover a larger area as the attributes of each hair are used to the maximum, but not at the expense of density or the appearance of fullness.

best wishes

 

[Hattingen Hair]

The redistribution of hair principle and the skills of the clinic to maximise them are the key secrets behind a successful hair transplant.

What is an adequate amount of hair that can be removed safely from the donor area to achieve an aesthetically pleasing coverage and density?

With a finite donor supply how is this possible?

How could hair loss evolve over time?

These are strategic considerations to be taken into account before deciding to undergo a hair transplant. The individual €™s hair characteristics, their goals and expectations will ultimately be dictated by the resources of the donor hair and the artistic and medical ability to ensure that the supply can reach the demand dictated by the surface area of the recipient area; and if not the goals and expectations will have to change. For this reason it is important to keep an honest dialogue between patient and clinic to ensure your goals can be met.

Angle and Orientation

As said earlier the FU ´s are placed in such a fashion, at specific angles, direction and positioning in relation to each other in order to obtain a nearly identical natural appearance. The angle and direction of each incision must be as precise as the appearance of the natural hair.

In the front areas for example, the angle should be acute, this helps to increase the coverage given by each hair unit with each unit overlapping the other, a €œtile effect €.

The "crown" is a good example how the distribution of grafts can give the illusion of fullness without destroying the donor area as the crown can require many more grafts that treating a similar size surface in the frontal due to the spiral effect of the crown, less over lapping of each hair and changes in angle and direction.

Thickness of the Hair Shaft, Hair Calibre and Natural Groupings

Very basically the thicker the diameter of the hair shaft the more surface area it will cover, fine wispy hair requires more physical hair to cover the same area and to achieve the look of fullness.

Natural hair groups, single units to 3 and 4 hair units, this is different to density; density is the number of natural units you have, calculated per cm ², but does not take into consideration the number of hairs in the same area. Typical the sides of the donor have a lower density and hair count compared to the back where there typically a high actual density and also hair count.

As an example it is possibly to have a high density per cm ², 80 FU cm ², but a low hair count if the majority of units are made of single and 2 hairs, this could mean only 120 actual hairs, compared to the same density but a balance of natural hair units resulting in 176 actual hairs.

If this is multiplied over a procedure of 3000 grafts the effect is dramatic in terms of the amount of coverage that can be achieved, short and long term, and possibly render them a non-suitable hair transplant candidate, dependent their hair loss stage and potential for future loss.

Colour Contrast

The greater the colour contrast between the hair colour and scalp pigmentation the higher the perceived colour contrast is. With greater contrast it is harder to block the reflection of light whereas with a low contrast the scalp is less noticeable and easier to conceal, allowing for a greater coverage with fewer grafts required.

Hair Length in the Recipient

Having a very short/shaved hair style after a hair transplant is not something that is possibly for the vast majority of hair transplant candidates.
The object of a hair transplant in the recipient area is to give coverage over the scalp and the illusion of thickness or a good head of hair. To achieve this hair has to be kept at a certain minimum length or longer so each hair covers, or lies over the surrounding hair. This has the effect of creating layers of hair that block light from reflecting off the scalp, the more the light is blocked the greater the illusion of density.

The shorter the hair, and if shaved all illusion of density is taken away and as it is impossible to replace like for like hair as before hair loss the result can appear unnaturally thin.

The thought of very short or shaved hairstyles should be viewed with a little caution as there are very few people who have the donor hair capacity and excellent hair characteristics to achieve this type of look from a hair transplant, especially higher NW patterns.

A hair transplant basic premise is to cover a bare scalp with hair by a reasonable compromise between graft density and hair characteristics. Therefore it makes aesthetic sense to allow the transplanted hair to grow a little to increase the look of fullness.

 

[Boberto]

Nice informative posts there. Good information.

I know what your saying on the shaving point regarding having the hair a certain length to curtain the scalp.

However I seem to pull off the buzzed look pretty well after my HT. Ive been shaving down to 1mm and i dont believe it looks unnaturally thin i have to say.

 

[Hattingen Hair]

Hi Boberto,

You look good and glad you can get down to a low level; best wishes for the months to come.

If you look at your case it illustrates what we are saying. You had a conservative approach, the best part of 3000 grafts were able to be placed slightly into the mid section because of this, and the distribution allowed, with your hair characteristics for this to be possible.

I am sure the design and approach took into consideration you hair characteristics and also your goals, so long term your donor can meet the demands if hair loss progresses and you can still meet your goals.

Best wishes and good growth to you

That is a reason why it is important that a plan is set out to ensure your goals are equal to your donor potential. In your case it was possible but not for all and what we tried to show was disclosure in respect that not all can achieve what you have, and good for you!

 

[Boberto]

Hi Hattingen, thanks for the comments. Yes i guess i should count myself lucky in the respect.

A conservative approach was definitly my thinking as to keep donor in the bank should loss progress. Ive been told i have good donor density for any future work and i had a high number of 3's and 4's and even a 5 .

Hopefully all bodes well for final result.

And agreed very important adequate plans and goals all meticously gone through at the outset with patient and clinic.
Thanks for the informative posts.

 

[Hattingen Hair]

Boberto wrote:

Hi Hattingen, thanks for the comments. Yes i guess i should count myself lucky in the respect.

A conservative approach was definitly my thinking as to keep donor in the bank should loss progress. Ive been told i have good donor density for any future work and i had a high number of 3's and 4's and even a 5 .

Hopefully all bodes well for final result.

And agreed very important adequate plans and goals all meticously gone through at the outset with patient and clinic.
Thanks for the informative posts.

Hi Boberto,

Thanks for the comments about the thread.

With a conservative approach as you have taken it means greater coverage further back with an amount of grafts, allowing to blend back into the native hair with fewer grafts.

With a good hair count per unit it will also allow for the grafts to be spread slightly further and maintain a natural look. The hair count is very important and sometimes overlooked as the focus is often on the density measurement per cm ², but without the higher natural groupings this is not possibly; if for example the hair count is around 20% less it will totally change the complexion and planning of a hair transplant, especially so with FUE as the density in the donor drops every procedure.

Once again, good growth to you.